The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 100 employees. This review focused on six operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) pressure ulcer prevention and management and (2) nurse staffing. The facility’s reported accomplishment was an improved orthopedic surgery joint replacement patient flow process, which allows patients to stay on the same unit for post-surgical care and rehabilitation. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspections, (4) coordination of care – hospice and palliative care, and (5) follow-up on environment of care issues.